Opening the Patient-Clinician Discussion about the Link between Cognition and Hearing

I’ve spent my entire life fascinated by the brain. I told my parents I was going to be a neurosurgeon before I finished elementary school, later completed an undergraduate honours degree in Neuroscience, and probably would have continued along that route had I not had my face crushed in a sports accident at 21 years old. Oddly enough, taking that line drive to the face was probably the best thing that ever happened to me. It led me to the field of audiology, which has been an incredibly rewarding personal and professional journey for the past 12+ years. I think audiology has the perfect mix of interpersonal interaction, technical advancements, and professional collaboration, all intertwined in a medical framework around arguably the most important aspect of humanity, communication. Audiology has provided us with a body of knowledge that allows us to assist with an incredible number of difficulties the average patient has (hearing, balance, tinnitus, aging, cognitive function, medications, and aural rehabilitation strategies to name a few); but how do we make our message effectively heard? How do we impart our immense knowledge and act as a “bridge” to so many aspects of their lives without creating other problems in the meantime? Furthermore, how do we do this in a timely manner while still generating revenue for our clinics? I don’t think any blog post could answer all the potential questions from these thoughts, and I don’t believe I personally have all the answers in any case, so I decided to focus on a topic we’ve all been inundated with from every angle over the past few years: cognitive difficulties relating to hearing loss and impacting communicative success.

It often crosses my mind what patients think I’m trying to accomplish when I begin discussing cognitive function during the time spent with them and their families. Do they think it’s a sales tactic? A scare tactic? Do they believe what I’m saying? What’s more, once we begin discussing things like dementia or Alzheimer’s, energy levels, or memory loss, do they shut down and stop taking in new information? Do their minds cloud over with the simple revelation that they’re potentially damaging their brains if they have a hearing loss and are not getting assistance? Does auditory deprivation make sense to them? Do they understand the concept that you actually hear with your brain? Once again, I feel that we as audiologists have some unbelievably relevant information to impart on these patients,  but I don’t think we all utilize this evidence in the most effective manner. During these conversations, I often find myself informing patients of the fact I have a degree in brain and spinal cord function, and welcome the comforting smile on their faces as they realize I do have some knowledge about this intimidating topic. But, do all audiologists have this reservoir of knowledge from their educational past? The majority likely do not, so how do those clinicians gain their patient’s trust to confer this? We are all being tasked with discussing a critically important topic in a very intimate setting, and we may be failing our patients if we cannot improve our presentation and thus, their reception.

My three biggest concerns are centered around our patients perceiving that we are:

  1. creating urgency to make a sale,
  2. fear mongering, and
  3. talking over our heads.
To be honest though, given the stereotypical perception of hearing aids, could anyone blame them for feeling that way? Right or wrong, our industry has been plagued by a lack of respect from both the general population and the medical community for many decades. This is even more apparent in private practice settings where expensive hearing aids often don’t fix the underlying issues to the satisfaction of the patient, and many patients come in already expecting the outcome of this process will be less than exemplary. There is a significant percentage of physicians who don’t fully understand or appreciate the skill set of an audiologist, and there is a significant percentage of the general population who view us simply as hearing aid sales people. We ponder why they equate audiologists with hearing instrument practitioners, yet many audiologists do little to distinguish themselves as medical professionals critical to their communicative well-being. I believe a knowledgeable discussion of the impact of hearing on cognition is an outstanding avenue we can use to gain the respect and trust of our patients. Who else is equipped to discuss such a topic with a concerned patient? Audiologists alone understand the audiological details of their particular case, their specific communication concerns, the health of their auditory transmission pathways, and the neurological processing capabilities critical to the success of the entire venture. No other health care professional is positioned to provide such a detailed assessment of this process, and we need to ensure the patient gets what they deserve from their time with us. Audiologists have a crucial role to play, but we need to ensure the information is presented appropriately to minimize the likelihood of patients perceiving one of the three concerns listed above.

So, how do we go about this? There is no one correct answer, of course, but I always attempt to begin this process with a thorough explanation of speech audiometry results. Speech testing helps us to understand how their brain processes language at low and high input levels, in both simple and complex environments, and it often helps to validate their complaint that they “can hear people talking but can’t understand what they’re saying.” Relationship building in audiology is critical for long term success, and properly explaining those results goes a long way towards our patients trusting in our expertise. Many years ago, during my first visit to the IDA Institute in Denmark, we discussed the necessity of the pure tone audiogram, and why many audiologists spend so much time explaining this aspect of the assessment. The general consensus was that audiologists spend more time than necessary on describing pure tone thresholds and degree of loss. At this point in my career, I often spend more time explaining impedance than pure tone hearing loss. Patients do not seem to care if they have a mild loss or a severe loss; they’re concerned that we understand their problems hearing and understanding speech, and that we can provide some remediation for their challenges. Speech audiometry is an easy avenue to that discussion, and allows us to really drive home the point that you hear with your ears but understand with your brain. Once they grasp that concept, it’s a pretty simple jump to appreciating that the ears stimulate the brain; so, if they aren’t hearing properly, then the brain is not being properly stimulated.

Everyone understands that “if you don’t use it you lose it,” but my patients often feel the sense of hearing does not apply in this context because they can still hear. It’s a very logical position to take, especially if they don’t recognize that they have a hearing challenge in the first place (or if they haven’t admitted it yet). Their hearing loss typically impacts them in some, but not all, environments; so, the linkage between appropriate hearing and neurological health is not always evident. To help clarify this connection, I try to spend time showing them a simple diagram of the ear (including eardrum, Eustachian tube, cochlea, vestibular system, etc), then explaining which pieces of the puzzle are problematic in their case. Often this stage can be as quick as telling them every aspect of that system works fine (other than the cochlea), that the more pressing issues are higher up in the brain, and then spend my counselling time focussed on neurological processing. At Audiocorp, we are heavily invested in the long term family-based approach to amplification and counselling, so we do our utmost to repeat our message on cognitive function throughout the trial period and beyond. We have developed a series of handouts that support this message and afford people the opportunity to reconsider and digest this information outside of our office. Moreover, in using the handouts and thoroughly covering the topic in this manner, we have found that at follow-up appointments our patients (and their families) tend to ask more questions about neurological health, provide examples of things they’ve witnessed since the previous appointment, and even report that they’ve sought out additional information on our website or from other online sources. It promotes understanding on the part of the communication partner, a greater level of patience when dealing with the ramifications of auditory degradation, and provides us another ally in monitoring their hearing condition over time. It engages people in their own remediation, encourages the patient and their family to commit to the process of assisted hearing, and fosters the connection between patient and clinician to the betterment of all involved.

At this early stage of the interaction, once we have discussed such a large amount of eye-opening material and the patient is beginning to solidly grasp the concept, I will often recommend that
we end the appointment and have them come back in for a secondary consultation in 2-4 weeks. We provide them with whatever handouts are deemed relevant for their particular case, ensure all their
questions are answered, and book their next appointment. This is the point where I believe many clinicians lose the connection between neurological decline and the selling of hearing aids. If we
immediately jump into the discussion of buying hearing aids when a patient is reeling from learning their brain may have been damaged by their hearing loss, they very well might see it as a scare/sales tactic for the audiologist’s benefit. However, in my experience, taking the extra time to work with each individual patient and their family members on this advanced level causes nothing but outstanding word of mouth advertising. If you want to stand out in a crowded market, do something extraordinary. Go that extra mile, spend that extra time focussing on the patient in the short term, and they will be more successful and likely to refer other patients to you in the long term. We cannot be short-sighted on this topic and deal with the apprehension that comes from potentially “losing a sale.” The patient will naturally be more committed to the process due to their heightened understanding of the underlying concerns; which subsequently results in greater rates of compliance and successful hearing aid use. Happy hearing aid users are not as common as we would like to see, this is one simple method of helping to change that unfortunate situation. We all love when a professional takes the time to really get to the bottom of our personal issues, so why not strive to be the professional who also provides that type of care?

To summarize, I would like to reiterate that these methods have worked very successfully for myself and the other audiologists we employ, but it is by no means the only way to address cognitive function relating to hearing. Speech testing, patient and family education, multiple appointment intervention coupled with handouts, reinforcement of important concepts, and patient-specific aural rehabilitation is nothing new to us as audiologists; but I believe we can incorporate neurological processing and cognitive function into that discussion, and impart this new realm of knowledge as easily as we teach them about their moderately-severe sensorineural hearing loss. When we’re uncomfortable we tend to revert back to what’s familiar, but we can never optimize our potential as an industry if we don’t integrate this extremely important topic into our daily counselling of patients. It elevates us as knowledgeable medical professionals, it provides the patient with greater confidence in our ability to care for them, it results in more compliant hearing aid users, it results in greater numbers of word-of-mouth referrals, it separates you from your immediate competition, and, last but certainly not least, it gives us greater satisfaction as audiologists who have provided an enhanced level of hearing health care.
We are the bridge between hearing, neurology, and patient intervention, and I believe we need to include the discussion of cognitive processing to fully address the topic at hand. We can do more, we
can be better, and everyone wins in the long run.

Author: Trevor Menchenton, Clinical Audiologist, President of Audiocorp, MSc.

Watch the video of Dr. Vincent Lin, a renowned cochlear implant researcher and associate scientist at Sunnybrook Hospital, discuss the correlation between hearing loss and dementia. He gives tips about the warning signs to look for in family members, and discusses the research that’s looking into how cochlear implants may affect the course of dementia progression.

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